Several pandemics have occurred throughout human history, most recently those caused by smallpox, cholera, plague, influenza, Ebola, severe acute respiratory syndrome (SARS), West Nile disease, and COVID-19 (1, 2). Pandemics have infected millions of people, resulting in widespread illness and thousands of deaths (3, 4). Apart from the debilitating and sometimes fatal effects on those directly affected, pandemics have a slew of negative social, economic, and political consequences (5, 6). Pandemics have enormous ramifications, particularly for women (7–9).

The pandemics have a systemic problem of human development that exacerbates challenges to gender equality (10, 11). The crisis disproportionately impacts women and girls on various social, economic, and political levels. Women lost jobs more rapidly than men, owing to the high percentage of women employed in hard-hit businesses such as restaurants and hotels. Women working in the informal economy have suffered from a lack of health care, unemployment benefits, and other protections (12). Pandemics are having an effect on gender disparity in health and education and the burden of unpaid care work and gender-based violence. While the pandemics affects everyone, women and girls suffer particular and frequently disproportionate economic, health, and social risks due to ingrained inequities, social norms, and unequal power relations (13). Understanding the gender-disaggregated effects of the pandemics crisis through sex-disaggregated data is crucial for developing policy solutions that minimize vulnerable conditions and improve women's agency while prioritizing gender equality (14). It employs impact evaluation research to identify policy alternatives to increase women's economic resilience and reduce any negative repercussions during the pandemics.

SDGs (Sustainable Development Goals) prioritize gender equality and empowerment and the elimination of all forms of discrimination against women (15). Despite progress toward gender equality, disparities persist in the form of sexual or intimate partner violence and social underrepresentation (16, 17). The difference becomes even more pronounced during unprecedented pandemics when women face adversity in the form of illnesses, economic burden, workplace or household stress, and more (18–20). Additionally, if a woman works, she must balance domestic responsibilities with professional responsibilities (21). Usually, women provided 70% of all health and social services staff globally (17). Moreover, the isolation and confinement may increase gender-based violence (22). Discord between women's personal and professional lives during a pandemic may have long-term consequences (23, 24).

Women generally have more experience using health facilities, whereas men may regard healthcare venues as “feminized” and frequently have low health literacy. This study provides an evidence-based overview of critical analysis of masculinities and pandemics in a gendered lens. It examines the impact of pandemics on men and women in various social groupings. It makes suggestions and recommendations to politicians and other decision-makers on addressing masculinity concerns during times of crisis. Pandemics exacerbate inequalities in women's health (12). Women faced additional obstacles in various ways during pandemics; however, there is less evidence focusing exclusively on women's health-related barriers. This study narrated the health challenges and coping women faced during pandemics.

A systematic review of the existing literature was conducted, emphasizing health-related challenges and coping strategies among women during pandemics. We registered the protocol in PROSPERO (CRD42020187826), and the findings were reported following PRISMA guidelines (25). We conducted a thorough search of the MEDLINE (PubMed), PsycINFO (ProQuest), and CINAHL (EBSCO) databases to identify studies published between January 2000 and September 30, 2020.

We identified qualitative studies that documented the difficulties faced by women during pandemics. The titles and abstracts of the articles retrieved from the database were screened. The full text of the studies was independently screened by the authors (MRS and SD), and KCS resolved any disagreements. We included studies involving women of any age group. We excluded commentary, reviews and studies that did not meet the objective.

The authors (MRS, SD) independently extracted data from the included studies, with disagreements resolved by consulting a third reviewer (KCS). The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to assess the quality of studies (26) by two authors (MRS, SD) independently (Supplementary Material 1). We used thematic analysis (27) to synthesize the data and identify recurrent themes. The authors read and reread each article to identify potential codes, categories, and themes, as well as coded data, using MAXQDA Analytics Pro 2020 (VERBI GmbH Berlin).

After screening 2,831 abstracts, 141 were considered relevant for full-text review, and finally, 17 were included (Figure 1). Included articles were on influenza (n = 3), COVID-19 (n = 5), Zika (n = 5), Ebola (n = 2) and SARS (n = 2). Eight studies reported reproductive health, while the remaining seven explored primarily psychosocial health (Table 1). The major themes were (1) Reproductive health, (2) Psychosocial health, and (3) Coping strategies and support systems (Table 2).

The studies were conducted in Africa, Asia, Australia, Brazil, China, Colombia, Georgia, Honduras, Hong Kong, Latin America, Puerto Rico, Scotland, Sierra Leone, the United Kingdom, and the United States. In 11 studies, the participants were exclusively women; in the remaining studies, more than half of the participants were women. The study participants were female community members and female healthcare professionals. All the studies were qualitative and collected semi-structured interviews or focus group discussions.

Women's reproductive health is determined to be significantly harmed as a result of impeded reproductive, maternity, and child health care due to human resource constraints, as reported by 66% of nations (45). Disruptions in health services increased demand for home births, either out of fear or insufficient support in institutions (46–48). Lack of knowledge or information, lack of permission from family or husband to access facility, geographical barrier, lack of understanding of prevention methods, and fear of infection were the top barriers women faced in accessing health care (49). Frequent policy changes left end users, and service providers perplexed about how to deal with the situation, resulting in a negative impact on sexual and reproductive health services (50, 51).

Globally, domestic violence against women has escalated, exposing these victims to sexual assault and distress (52). Reduced access to alcohol and tobacco products frequently increased violent behavior, exacerbating domestic abuse. Additionally, a dearth of contraception during pandemics exacerbated undesired pregnancies (53). During emergencies, exposure to hygienic goods has decreased, posing health dangers (54). Job loss has economic consequences, making it even more difficult for women of low social status, particularly in developing countries, to get proper maternal health care; this exacerbates anxiety and grief and increases violence against women (52). Pandemics also exacerbate malnutrition among the poor, owing to food instability, resource constraints, and financial insecurity (55). On the other side, physical activity has been reduced due to the lockdown, resulting in a huge increase in the number of obese wealthy individuals; as a result, the risk of non-communicable disease has increased (56).

Women are disproportionately more likely to experience situations in the workplace that demand them to display resilience when they are underrepresented at the top levels of decision-making (57). A resilient person adjusts and responds to stressors in various ways, including embracing the new reality or improvising through efficient coping mechanisms (58). Individuals may have functional or dysfunctional coping strategies; however, positive coping mechanisms are likely to result in improved resilience; hence, coping and resilience, while distinct, are also related. It is necessary to understand the women's capacity to manage and develop resilience in various situations to address women's vulnerabilities (59). It is critical to examine organizational power systems from a resilience and gender viewpoint. As a result, the female perspective on resilience challenges the mainstream masculine discourse on resilience in the context of pandemics (59).

Despite obstacles, women remained resilient, adapting to their circumstances in various ways. Throughout the pandemic, the avoidance of travel, visiting or meeting new people, and going to work were embraced to cope with the crisis (60, 61). Positive outcomes are associated with problem-solving strategies, whereas emotional coping mechanisms such as blaming, avoiding, and ruminating have negative consequences for depression and anxiety (62). Self-care activities such as hygiene and social support aided in managing the pandemic condition (60, 63).

During pandemics, women are at an increased risk. Furthermore, more than 70% of community health workers worldwide are female. During pandemics, multifactorial challenges are exacerbated in a unique way among women. To combat health disparities during pandemics, gender-informed policies are required. There is a need for a more in-depth understanding of the potentially gendered nature of crisis response and the identification of new research avenues.

Regardless of their roles and responsibilities in society, women faced a slew of health-related challenges during pandemics. Gender inequity during pandemics should not be overlooked in reporting. Women must have equal rights and opportunities, free of discrimination, which necessitates immediate action to improve women's rights and achieve the SDGs. Women's engagement in pandemic-related services should be investigated, as this will aid in the development of strategies to reduce vulnerabilities.

MRS and SD designed the systematic review under the supervision of KCS. MRS and SD synthesized and analyzed the data, drafted manuscript, and revised the drafts based on comments from other co-authors. KCS and SP reviewed the various versions of this manuscript and provided constructive comments. All authors read and approved the final manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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